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Project Lazarus: Communitybased Overdose Prevention in Rural North Carolina

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Project Lazarus: Communitybased Overdose Prevention in Rural North Carolina Pain Medicine 2011; 12: S77–S85 Wiley Periodicals, Inc. Project Lazarus: Community-Based Overdose Prevention in Rural North Carolinapme_1128 77..85 Downloaded from https://academic.oup.com/painmedicine/article-abstract/12/suppl_2/S77/1918825 by guest on 29 October 2018 Su Albert, MD, MPH,*†‡ Fred W. Brason II, Results. Preliminary unadjusted data for Wilkes Chaplain,*‡§ Catherine K. Sanford, MSPH,* County revealed that the overdose death rate Nabarun Dasgupta, MPH,¶ Jim Graham,‡ and dropped from 46.6 per 100,000 in 2009 to 29.0 per †‡ Beth Lovette, MPH 100,000 in 2010. There was a decrease in the number of victims who received prescriptions for the sub- *Project Lazarus, Moravian Falls, North Carolina; stance implicated in their fatal overdose from a Wilkes County physician; in 2008, 82% of overdose †Wilkes County Health Department, Wilkesboro, North decedents received a prescription for an opioid Carolina; analgesic from a Wilkes prescriber compared with 10% in 2010. ‡Northwest Community Care Network, Winston-Salem, Conclusions. While the results from this North Carolina; community-based program are preliminary, the number and nature of prescription opioid overdose §Wilkes Healthy Carolinians Council, Wilkesboro, North deaths in Wilkes County changed during the inter- Carolina; vention. Further evaluation is required to under- stand the localized effect of the intervention and its ¶Department of Epidemiology, Gillings School of potential for replication in other areas. Global Public Health, University of North Carolina at Key Words. Overdose; Prescription Monitoring; Chapel Hill, Chapel Hill, North Carolina, USA Opioids; Chronic Pain; Community-Based Research; Surveillance Reprint requests to: Fred W. Brason II, Chaplain, Project Lazarus, P.O. Box 261, Moravian Falls, NC 28654, USA. Tel: 336-667-8100; Fax: 866-400-9915; Introduction E-mail: [email protected]. In response to some of the highest drug overdose death rates in the country, Project Lazarus developed a community-based overdose prevention program in Abstract Western North Carolina. Wilkes County is one of the largest land mass counties in North Carolina, covering Background. In response to some of the highest over 700 square miles in the foothills of the Appalachians drug overdose death rates in the country, Project with a current population of approximately 66,500. His- Lazarus developed a community-based overdose torically, logging, textiles and manufacturing, and cattle prevention program in Western North Carolina. The and chicken farming have been primary industries. In the Wilkes County unintentional poisoning mortality 1930s, prohibition brought about moonshine activity; rate was quadruple that of the state’s in 2009 and Wilkes is the birthplace of National Association for Stock due almost exclusively to prescription opioid pain Car Auto Racing, a sport with an explicit history inter- relievers, including fentanyl, hydrocodone, metha- twined with moonshine, suggesting generations of sub- done, and oxycodone. The program is ongoing. stance misuse and abuse at the margins of the law. With much physically demanding employment, Wilkes has a Methods. The overdose prevention program significant population that suffers the physical conse- involves five components: community activation quences of work-related injuries, with a substantial burden and coalition building; monitoring and surveillance of chronic pain. The unemployment rate consistently data; prevention of overdoses; use of rescue exceeds the national average and combined with poverty medication for reversing overdoses by community and limited educational opportunities, creates a cycle of members; and evaluating project components. Prin- socioeconomic depression. cipal efforts include education of primary care pro- viders in managing chronic pain and safe opioid The Wilkes County unintentional poisoning mortality rate prescribing, largely through the creation of a tool kit (primarily from drug overdoses) is quadruple that of North and face-to-face meetings. Carolina’s (46.6 vs 11.0 state mortality rate per 100,000 S77 Albert et al. Table 1 Coalitions and organizations involved in community-based response to opioid overdose deaths in Wilkes County, North Carolina Entity Description Responsibility 1 Substance Abuse Task Force, County-level partnership Raising awareness of overdose Wilkes Health Carolinians supporting coalition building problem Council for health actions Downloaded from https://academic.oup.com/painmedicine/article-abstract/12/suppl_2/S77/1918825 by guest on 29 October 2018 2 Chronic Pain Initiative, Regional (substate) Medicaid Clinical education on pain Northwest Community Care authority, including 70 management; policy changes Network practices and 58,000 for Medicaid beneficiaries; patients in six counties seed funding for community-based response 3 Wilkes County Health Local health department Data review and collection; Department authority for action; meeting facilities 4 Project Lazarus Nonprofit organization Coordination of efforts between organizations and individuals; school-based education; community outreach; promotion of drug treatment; evaluation population per year in 2009) and due almost exclusively to tion of overdoses; use of rescue medication for reversing prescription opioid pain relievers [1]. Top opioids impli- overdoses by community members; and evaluating cated in deaths include fentanyl, hydrocodone, metha- project components. The last four steps operate in a done, and oxycodone; heroin is rarely suspected in cyclical manner, with community advisory boards playing overdose deaths. The average age of death is in the late the central role in developing and designing each aspect 30s, and decedents have considerable comorbid health of the intervention. conditions, including respiratory, circulatory, and meta- bolic disorders. Those who are dying are county residents At the center of Project Lazarus is the understanding that who use opioids for both medical and nonmedical reasons communities are ultimately responsible for their own and exceeded their physiologic tolerance, either directly or health and that active participation from a coalition of in combination with other licit or illicit substances [2,3]. community partners is required for a successful public health campaign. The community-based organizations Decades of studies about drug misuse and overdose primarily responsible for responding to the overdose within North Carolina have contributed to a nuanced problem in Wilkes County are presented in Table 1. Com- understanding of the nature of deaths [2,4–9]. In a study munity activation describes the concrete actions required of Medicaid beneficiaries who died of a methadone over- to bring communities together to develop a health promo- dose, state health department researchers found that in tion scheme and to build long-term social capital. The the 34 days prior to death, 30.7% of decedents had Project Lazarus model is based on previous research on codes for methadone maintenance for addiction, while community activation for health promotion, which indi- 57.7% had codes for outpatient dispensing, most likely cates that the following organizations are the most impor- for chronic pain [10]. These findings were similar to an tant for successful public health campaigns: health earlier study conducted by a Project Lazarus staff department, schools, governmental agencies, hospitals, member in conjunction with the Centers for Disease primary care clinical practices, churches, and newspa- Control and Prevention [9]. A study of a pain clinic at a pers; the following organizations have also been identified North Carolina academic center revealed that 32% of as having a role in health promotion in nonurban areas: patients exhibited behaviors associated with misuse of television stations, health-related nonprofits, substance pain medications [11]. Taken together, these and other abuse treatment centers, and colleges [12]. local data form the basis for designing the Project Lazarus prevention strategies. The overdose prevention activities and their years in operation, as designed by the community coalitions, are Drawing upon successful public health campaigns in injury outlined in Table 2. These “bottom-up” interventions were prevention, Project Lazarus created a model for prevent- designed and developed by local individuals, agencies, ing prescription opioid overdose deaths that includes the and organizations that leveraged existing resources or following five components: community activation and coa- raised awareness and funds for new programs. The role of lition building; monitoring and surveillance data; preven- Project Lazarus has been to coordinate these efforts, S78 Project Lazarus Community-Based Overdose Prevention Table 2 Activities and timeline of community-based prevention of overdose No. Activity Years of Operation Community organization and activation 1 Town hall meetings 2006–present 2 Specialized task forces 2005–present 3 Community-based leadership 2005–present Downloaded from https://academic.oup.com/painmedicine/article-abstract/12/suppl_2/S77/1918825 by guest on 29 October 2018 4 Coalition building 2005–present 5 “Managing Chronic Pain” tool kit assembled 2007–2008 Prescriber education and behavior 6 One-on-one prescriber education on pain management (“academic detailing”) 2008–2010 7 Continuing medical education sessions on pain management 2008–2010 8 Licensing actions against prescribers by state medical board 2008 9 Promotion of CSRS 2007–present Supply
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